The charge nurse observes a nurse performing interventions for a client who has just arrived in the post-anesthesia care unit following right cataract removal and intraocular lens implantation. Which intervention would require the charge nurse to intervene?
The nurse waits 5 minutes between administering prescribed eye drops.
The nurse leaves the eye shield in place while the client sleeps.
The nurse is instructing the client not to drive at night.
The nurse encourages the client to exercise with 20 lb weights 1 day post-operatively.
The Correct Answer is D
Choice A reason: The nurse waiting 5 minutes between administering prescribed eye drops is a standard practice to allow each drop to be properly absorbed and avoid dilution of the medication. This intervention does not require any action from the charge nurse.
Choice B reason: Leaving the eye shield in place while the client sleeps helps protect the eye from potential injury or infection after surgery. This is a recommended practice and does not need intervention from the charge nurse.
Choice C reason: Instructing the client not to drive at night is a reasonable precautionary measure given the client's recent eye surgery and potential vision changes. This instruction does not warrant intervention from the charge nurse.
Choice D reason: Encouraging the client to exercise with 20 lb weights one day post-operatively is inappropriate and requires the charge nurse to intervene. Strenuous activity can increase intraocular pressure and compromise the healing process after cataract surgery. The client should avoid heavy lifting and follow the post-operative care instructions provided by the healthcare team.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","B","C"]
Explanation
Choice A reason: Using non-technical language helps ensure that the client can understand the information being communicated, especially when they have difficulty remembering details due to elevated BUN levels affecting cognitive function.
Choice B reason: Giving simple instructions makes it easier for the client to follow and retain the information, reducing the likelihood of confusion or errors in their care routine.
Choice C reason: Including the family in discussions related to care helps ensure that the client has support and that the family members understand the necessary steps for the client's treatment and recovery. This approach also helps reinforce the information for the client.
Choice D reason: Lengthy teaching methods may overwhelm the client, especially when they are experiencing difficulty remembering information. It is more effective to provide concise and clear instructions.
Correct Answer is D
Explanation
Choice A reason: A high purine diet is more commonly associated with gout and hyperuricemia, not cholinergic crisis.
Choice B reason: A high protein diet is not directly related to cholinergic crisis. The crisis is related to medication levels rather than dietary factors.
Choice C reason: Not exercising enough is not a direct cause of cholinergic crisis. Physical activity levels do not impact the balance of acetylcholine in the body in this context.
Choice D reason: A cholinergic crisis occurs due to excessive accumulation of acetylcholine, often from taking too much of prescribed anticholinesterase medications. This can lead to overstimulation of the neuromuscular junction and symptoms such as muscle weakness and respiratory distress.
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